'I’d love to magically swing the wand and fix it, but really that’s not our job'

Dr. Peter Lennox and Dr. Sheina Macadam inside their surgery room in Vancouver, B.C. on August 28, 2012. The number of mastectomy patients waiting for delayed breast reconstruction surgery in Vancouver was so overwhelming that the in-demand plastic surgeon was forced to stop accepting new delayed cases. In 2009, Dr. Sheina Macadam was recruited to help handle the workload.

Photograph by: Mark van Manen
, Vancouver Sun

The ancient Egyptians described it as a “coagulum of black bile” within the breast.

In their papyrus writings, dating back to 1600 BC, they surmised that getting rid of the excess bile¬ — through surgery, special diets, purging or even attaching leeches to draw out the bad blood— could cure the disease.

Breast cancer is not a new phenomenon, and neither are attempts at treating it.

In 1889, American surgeon William Halsted, a founder of renowned Baltimore teaching hospital Johns Hopkins, performed the first radical mastectomy. The disfiguring procedure, which removed the entire breast and pectoral muscle, prevailed as the standard treatment for most of the 20th century.

It wasn’t until 1963, with the invention of the silicone gel breast implant, that modern reconstructive techniques emerged.

Over time, breast reconstruction has become less invasive and more refined. With the delicate surgical options that surgeons have at their disposal, women rarely need to live without breasts.

Yet relatively few women, about one in 10 in Canada, ever undergo reconstruction.

The hurdles women face in getting the surgery are accepted by many as a fact of living in a country with a universal health-care system with its seemingly infinite list of patients and finite pool of resources.

In the final instalment of this six-part series, Canadian plastic surgeons debate solutions for the problems that prevent many women from receiving an important final procedure in their breast cancer treatment.

THE 'SURGEON FINDER'

Ottawa plastic surgeon Dr. Nicolas Guay is a strong proponent of women educating themselves about breast reconstruction to get the most out of the health-care system.

Guay launched the website as a resource for Canadian women seeking information on procedures last year.

“What was frustrating to me is that about 50 per cent of the patients I saw had seen somebody else and were unsatisfied with the options they received,” Guay said in explaining how the idea for the website came about.

In Canada, Guay said, “patients are not fantastic health-care consumers.”

“In the United States, they know how much they’re paying on a monthly basis just to receive care and they shop for their options,” he said.

But in this country, said Guay, “patients tend to let themselves be guided by the normal pathway of consultation that their surgeon has,” which can mean waiting years before they ever meet a plastic surgeon.

Through the website, women can search through a database of Canadian plastic surgeons who offer breast reconstruction. They can narrow the options based on whatever is their criteria for finding the ideal surgeon, be it shortest wait times, sex, language, or type of breast reconstruction offered.

When they have the name of a surgeon they would like to see, Guay said they can call to book an appointment, then secure the appropriate referral paperwork from their family physician or general surgeon.

“The surgeon finder is what’s really innovative,” said Guay. “Patients have the tools to select who is going to offer them the care instead of passively waiting for their usual pathway of care to happen.”

If patients are informed of their options, they can make the right decision for themselves, which can be incredibly empowering, said Guay.

Arming women with information before they set foot in a consultation room also helps to overcome the “white coat syndrome” that inevitably overcomes many patients when they finally do see a plastic surgeon, said Guay.

“It’s sort of an Oprah setting,” he explained. “They’re being informed in the comfort of their own home (where) patients are more inclined to listen ... to be in tune.”

The impetus behind Guay’s website is its collaborative aspect. More than 100 surgeons responded to Guay’s request for information about the types of procedures they offer, and are listed on the website.

The same collaboration is what Guay believes is the solution to changing how the health-care system approaches breast reconstruction.

Alongside piles of paperwork on Guay’s desk, a piggy bank rests with a tongue-in-cheek label inviting visitors to please make a donation to the “plastic surgery fund.”

Although its message is in jest, the knick-knack offers some insight into the struggle plastic surgeons face when lobbying for resources to cover breast reconstruction for their patients.

“I didn’t anticipate it being so important to be a spokesperson for my patients, but you do have to,” he said. “If we approach our ministries of health with a collaborative decision, a majority decision on how this care should be given in Canada, we are going to have the ear of the general public and we are going to have the ear of the politicians, and things will change.”

Finding the time to advocate for his patients, however, is easier said than done, said Guay.

“That’s where I think sometimes we fail as surgeons, in finding innovative ways to approach the administration, to approach the Ministry of Health and tell them in a very diplomatic and polite way . . . that we need more resources for this,” he said.

While many surgeons are quick to point to more funding as a fix, Winnipeg plastic surgeon Dr. Edward Buchel disagrees.

Instead, Buchel said the onus should be on doctors to develop more efficient and cost-effective ways of performing reconstruction within the existing pool of resources.

“We have to realize that we are sucking up more and more and more money to deliver the same care, and at some point, the system is going to have to go, ‘No, you as doctors have to figure out how to do this better and more efficiently, or the politicians will,’” said Buchel. “And it’s not going to be more efficiently. It’s going to be less care.”

In Winnipeg, Buchel has improved efficiency from both a surgical and administrative standpoint. In most hospitals, when a general surgeon teams up with a plastic surgeon to perform an immediate reconstruction, the general surgeon inadvertently ends up at a disadvantage.

“If you were a general surgeon, it might take you an hour and a half to do a mastectomy, and then you could do another case right after that,” explained Buchel.

But if a plastic surgeon then takes over to begin the reconstruction, which can take up to eight or 10 hours, “then your operating room is down.”

“You’re doing nothing for the rest of the day, and you’re not making any money,” he said.

Therefore, Buchel introduced a system where plastic surgeons offer up their own OR time for immediate breast-reconstruction cases, essentially giving general surgeons “a freebie” surgery.

“It’s about making a very efficient use of the operating room so we don’t penalize any of the surgeons,” he said. “(General surgeons) get to use the operating room under plastic surgery time, and we work together.”

Buchel said he has also developed surgical techniques that have increased his operating pace by two or three times. Faster operations mean he can see more patients in the same amount of time, and reduce his backlog of delayed patients faster.

His increased efficiency impressed the regional health authority which then agreed to give him more operating time.

“We guaranteed that the resources would be used to eliminate a wait-list for any reconstructive surgery,” said Buchel. “Most regions would be thrilled if the physicians would get together and put forward a solution like this.”

Buchel has also worked to improve access to reconstruction for Manitoba women. His goal is to ensure all breast cancer patients know about reconstruction before they ever have a mastectomy.

After years of lobbying for change, Buchel said that today any woman diagnosed in Winnipeg is automatically informed of their options for reconstruction.

If a patient wants reconstruction, they see a plastic surgeon for a consultation before their mastectomy, said Buchel. If they are indifferent about reconstruction, they still see a plastic surgeon. Only those who are absolutely certain they don’t want reconstruction don’t get a referral, he said.

About 90 per cent end up seeing a plastic surgeon, he said. Of those, about 80 per cent go through with reconstruction.

“There is nobody that falls through the cracks,” he said. “There’s nobody that’s not offered it.”

LEGISLATING CHANGE

If the U.S. approach to raising awareness about breast reconstruction is any indicator, the real power to increase surgery rates in Canada lies in the hands of policy-makers.

Some states have passed laws to help bridge the information gap for women undergoing mastectomies.

In New York, for example, cancer surgeons are now legally required to discuss options for breast reconstruction with patients prior to their mastectomy, even if they have to refer the patient elsewhere for surgery.

Immediate reconstruction at the same time as mastectomy has also increased in the U.S., in part due to a recommendation by the Commission on Cancer of the American College of Surgeons in 2001 to incorporate the practice in the treatment of early-stage breast cancer.

Dr. Steven Morris, a plastic and reconstructive surgeon in Halifax, says he believes the onus is on government to address the problem in this country as well.

“I’d love to magically swing the wand and fix it, but really that’s not our job (as surgeons),” said Morris. “Although we’d like to, we don’t have the control of the different pieces of it to fix it. We’re just kind of like the guys on the treadmill working.”

To accommodate increasing demands for breast reconstruction, Morris said the “current paradigm for the allocation of resources needs to change.”

“In the current culture of reduced funding, it is difficult to justify an upgrade in spending for a single program,” he said. “And if something else has to be cut to accommodate increased breast reconstruction spending, what is it going to be?”

With an aging baby boomer population, Morris said he is bracing for the inevitable “crunch” on health-care funding.

The problem is compounded by patients becoming better informed through the Internet about cutting-edge medical procedures, which also tend to be more expensive, he said.

“There is no ethical body that will say, ‘No, we don’t do cardiac bypasses in people over 90,’” he explained. “There is a point when you pull the plug on the respirator and there is a time when you don’t do reconstruction on someone with metastatic breast cancer. But that’s not my decision. My decision is, as soon as my patient comes through the door, they’re the most important thing.”

WAIT TIME HELPLINE

A common barrier for mastectomy patients is difficulty navigating the health-care system. Seeking a second opinion on reconstruction from a plastic surgeon isn’t easy when there is a significant wait time for a consultation.

Dr. Stefan Hofer, chief of plastic surgery at Toronto General Hospital and head of the University Health Network’s Breast Restoration Program, said the solution to lengthy wait lists could be as simple as a telephone helpline.

In the Netherlands, where Hofer is originally from, if a person is facing a lengthy wait for an operation, they can call a helpline for assistance in finding a surgeon that can perform the procedure sooner.

“So the agency would actually call the office of the doctor ... and they would place people who had excessive wait times,” he explained.

A helpline could also prevent Canadian women from seeking surgery in the U.S. when they face excessive wait times in this country, said Hofer.

There are many surgeons in Canada with the skills to perform breast reconstruction who have shorter wait times compared to some highly sought-after surgeons in busy metropolitan areas who have longer wait lists, he said.

“You just have to find a person,” he said. “So I think then it is maybe better to have a database of surgeons who do specific procedures.”

RECONSTRUCTION VERSUS TRAUMA

Dr. Blair Mehling, a plastic surgeon in Edmonton, said he finds it mind-boggling just how much breast cancer survivors are willing to put up with on their quest for reconstructive surgery.

“It blows me away the length of time that women will wait just to see me for a consult and then for the surgery,” said Mehling, adding that he has had delayed reconstruction patients wait as long as five years for him to operate.

“Canadians are tolerant, though,” he said. “It’s not that they’re happy about it, but we’re very accepting of the flaws in the system.”

Mehling said the problem highlights a need for a shift in health-care policy.

In Alberta, he said, trauma cases — patients needing surgical care of physical injuries — appear to take precedence over cancer cases, which sees breast-cancer patients consistently being pushed to the back burner.

“Right now in Alberta, the wait time target to have a patient in for immediate breast reconstruction is three weeks,” said Mehling. “Trauma cases are supposed to be in the operating room within a week of us seeing the consult.”

The difference points to an official policy, “whether they recognize it or not, that places trauma at a higher priority than cancer,” he said.

“We don’t meet any of these targets, by the way,” he added.

In Edmonton, the main problem is a lack of plastic surgeons who offer breast reconstruction, said Mehling. Of those who do, many are expected to work several on-call emergency room shifts per week, which take up a lot of time that could be spent performing reconstructions, he said.

While the “knee-jerk response” would be to hire more plastic surgeons who do breast reconstruction, Mehling said, “you could equally make the argument that we could solve the problem by getting more plastic surgeons that do trauma.”

“That would free up those of us who have a focus on breast reconstruction and who have the training to do it,” he said.

The goal, said Mehling, is to develop a collaborative care centre where breast-cancer patients can receive all their care, from diagnosis to reconstruction, under one roof.

In Edmonton, cancer treatment is “extremely fragmented,” he said. Patients receive their various treatments at different hospital sites across the city. He himself has performed breast reconstruction at four different hospitals in Edmonton, he added.

“There’s huge benefits to that multi-disciplinary, collaborative care kind of environment,” he said.

But his hopes for a similar collaborative care model in Edmonton were dashed when a new women’s hospital, the Lois Hole Hospital for Women, was recently built in the city. For whatever reason, breast reconstruction was never included in the new hospital’s list of services, which Mehling described as a “wasted opportunity.”

“We’ve got this beautiful brand new hospital and they don’t even do mastectomies there,” he said. “There is no breast surgery whatsoever going on there, nor is there any motivation or interest in pursuing that opportunity.”

Mehling was trained in microsurgical breast reconstruction at the MD Anderson Cancer Center in Houston, Texas, where he said he was exposed to the collaborative care model.

However, he said he is skeptical that Canada could become home to a hospital like MD Anderson, even though it is a publicly funded hospital.

“Their whole system is geared toward excellence. It was (geared) to providing the best possible care to the greatest number of patients,” he explained. “In Canada, it’s the other way around. There is a downside to facilitating (excellence) because it just means it’s going to cost more money.

While they are aware health-care funding is tight, plastic surgeons Dr. Peter Lennox and Dr. Sheina Macadam are adamant that more OR funding is necessary to deal with the heavy breast-reconstruction patient load in Vancouver.

Both said they are struggling to work through a backlog of delayed reconstruction patients who are waiting two to three years.

“The government needs to fund more OR time,” said Macadam.

However, even if that were possible, Lennox said it would be difficult for him to use the extra OR hours within his existing schedule. Another plastic surgeon would be needed, he said.

“If we were given the time just for Sheina and I, probably it would be hard for us to utilize it because our schedules are so full,” he said. “There’s a whole bunch of variables in there. One is getting another surgeon, but you also need the resources to support it, so that’s the hard part.”

But in a universal health-care system, Lennox said he realizes requesting more resources is not always possible.

“At some point, society is going to have to decide what’s more important because it’s not an endless budget,” he said. “It’s a hard one to answer.”

A TWO-TIER SYSTEM?

Vancouver plastic surgeon Dr. Nancy Van Laeken said she wouldn’t be opposed to a two-tier health-care system to better handle the volume of breast reconstruction patients.

Van Laeken has privileges at the Cambie Surgical Centre, a private hospital catering mostly to patients with third-party medical insurance. Although patients can pay for some procedures there, breast reconstruction is not offered at this point, she said.

“I’m not sure if this is politically correct for me to say, but it would be nice to know that if that patient wanted to have that surgery done in Canada, that they could call up one of us,” she said.

“There are many aspects of the reconstructive piece that would be considered cosmetic, so it would be more accepting to go ahead and do that here because it is not a purely functional issue.”

Van Laeken’s solution is a reaction to Canadian women travelling to the U.S. and paying tens of thousands of dollars to get breast reconstruction.

Canada has many surgeons with a high level of expertise in breast reconstruction, she said, and “it’s a shame that our patients don’t have access to that expertise.”

But, if she were a patient facing the same lengthy wait lists for breast reconstruction, Van Laeken said she likely “would look elsewhere as well rather than waiting.”

While he is not opposed to the idea of a two-tiered health-care system in Canada, Winnipeg’s Buchel said he strongly disagrees with women paying for reconstruction when they have lost their breasts to cancer.

While some may argue breast reconstruction is akin to breast augmentation, a cosmetic procedure for which many women do pay, Buchel disagreed. He reasoned that breast reconstruction is no different than many other “covered” procedures, from cardiac bypass to hip replacement surgery.

“Most of the stuff we do, it’s all for quality of life,” said Buchel. “You know, you’re 65 or 70 years of age, and we’re spending $10,000 to $15,000 on these people on new hips for them. Very little of that is survival. That’s giving them a quality of life.”

Buchel is not opposed to a European-style two-tier system, “where there is a safety net, but everyone has the option of having their own private insurance.” But does he ever want to see cancer patients paying out of pocket for their cancer treatment?

Dr. Peter Lennox and Dr. Sheina Macadam inside their surgery room in Vancouver, B.C. on August 28, 2012. The number of mastectomy patients waiting for delayed breast reconstruction surgery in Vancouver was so overwhelming that the in-demand plastic surgeon was forced to stop accepting new delayed cases. In 2009, Dr. Sheina Macadam was recruited to help handle the workload.

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